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Kenya Lung health Training Course

Laboratory Diagnosis of TB
By the end of the course, the participants will be
able to:
• Demonstrate proper specimen collection and
• Establish a specimen referral network
• Conduct biosafety measures/activities
• Establish facility infection prevention and
• Conduct accurate, reliable and timely diagnosis
• Conduct quality assurance activities
Module 1: Specimen collection, processing and

By the end of this Module, participants will be able

• Describe procedures for specimen collection,
handling, packaging, storage, transport and
• Describe specimens for Tuberculosis diagnosis
• Describe how to establish and monitor a laboratory
specimen referral network
• Practice filling of recording and reporting tools
Collection sputum samples
• Sputum must be collected in the open air or in
a well-ventilated room reserved for this
purpose, as far away as possible from other

• Trained health personnel must:

Explain to the patient how to cough to bring

up sputum from as deep as possible in the

Open the sputum container, stand behind the

patient and ask him/her to expectorate with
his/her mouth close to the sputum container
Collection of sputum sample
• Close the sputum container securely.
• Wash their hands with soap and water before
giving a new container to the patient to be
returned to the health facility the next day with
a new sputum sample
• Ensure that the patient has understood how to
collect a sputum sample the next morning and
how to close the container securely
• Check the quality and quantity of sputum
collected (2–3ml of sputum containing solid
Sources of TB samples
Site Specimen

Lungs Sputum

Pleura Pleural Fluid

Central nervous system CSF

Lymphatic system Lymph fluid, Biopsy

Genitourinary systems Urine

Bones and joints Synovial fluid

At the community level, CHV will be supported
by the diagnostic facilities to
 Understand sample collection SOP
 Sample packaging procedures
 Storage and transportation of the samples (sample should
be delivered in 24 hours
 Timelines for the results back to the patient care point
• Samples should be examined at health Centre daily or
sent to a testing laboratory
• For storage and transport of the samples, special
transport boxes should be used that can each hold
10–20 containers
Laboratory request tools for AFB
Microscopy, GeneXpert and Culture
• Samples request forms for AFB, Genexpert
and Culture
• AFB/GeneXpert laboratory registers
• Sample tracking logs

Note: Laboratory request form should be fully

The following rules must be followed in
sample packaging and transportation
 Each sputum container must be clearly identified by a
label with the patient’s family name, first name and
register number on the side of the container
 The transport box with the sputum containers should
be kept as cool as possible. If the samples are to be
cultured they should be refrigerated at +4°C. (if not
refrigerated, the sample should reach culture lab
within 48 hours)
 A list of the patients’ names and information should be
sent with the transport box
How to establish a specimen
referral network
• Identify specimen referral coordination and logistics lead
at each level
– Facility, Sub-County, County and Culture laboratories
• Mapping of all TB treatment and diagnostic facilities
• Line listing of TB treatment facilities nearest to diagnostic
sites (network)
• Identification of a dedicated specimen transport system
(Motorbike, bicycle, vehicles, hand delivery, courier e.t.c.)
• Identification of results feedback
How to establish a specimen referral
• Ensure proper use of specimen recording and tracking
• Training of HCWs at facilities on specimen flow and
results feedback
• Training of specimen transporting personnel on tracking,
safety and timeliness requirements
• Sensitizing HMTs on specimen referral budgetary
allocation needs
• Train specimen referral coordinators on monitoring and
evaluation, targeting key performance indicators
• Routinely track and address needs for continuous
Acceptable Specimen quality

Purulent Mucoid
(Images courtesy of A. Van
Sample packaging
Packing & shipping infectious
Primary Absorbent packaging material

Secondary container
Study #
Specimen record
Screw-on cap

Biohazard label
Outer (tertiary) container
Address to

Address from
Address label
Specimen referral networks
Where to send specimens for testing:
– Within the Gene Xpert machine facility
– To the nearest Gene Xpert machine facility either
within or outside your County
How to send specimens for testing:
– Ensure specimens are properly and safely packaged
– Use available facility transport( GOK, partner)
– Facilities are encouraged to integrate Xpert
specimen referral with existing CD4, viral load, EID
How will results be returned?
– Electronic through emails
– Hard copy using existing transport mechanisms(
partner, GOK)
Role play

• Filling of laboratory request forms

• Sputum collection procedures

Module 2: Laboratory biosafety

At the end of this module the participants

should be able to understand:
1. The transmission of TB bacilli
2. Risk assessment and precaution levels
Importance of safety in the
• Following laboratory biosafety procedures
prevents laboratory staff from becoming
infected with TB and prevents
microorganisms from being released into
the environment
Specialized equipment may aid good laboratory
practice but does NOT replace it
Always wear gloves and laboratory coats when
handling samples from patients
Transmission of TB bacilli in the
• The main risks in a TB laboratory are related to
the aerosols generated during the procedures
that could be inhaled by laboratory workers
• The risk of aerosolization is associated with the:
Type of procedure
Frequency of testing, and the laboratory’s workload
Consistency of the material and its predisposition to
aerosolize (for example, viscous liquids versus dry
Bacillary load of the materials
New approaches to biosafety are based on
risk assessments

• WHO has adopted an approach that

assesses the risks associated with different
technical procedures performed in different
types of
TB laboratories.
Risk-group classifications and containment levels
(BSLs) are no longer used.
WHO’s biosafety manual for TB laboratories
describes the MINIMUM requirements for
facilities, and the practices that can be adopted
following a risk assessment
What is a risk assessment?
• A risk assessment is simply a careful examination of
what in your work could cause harm to people.
• A risk assessment must consider:
 The bacterial load of materials, and the viability of TB bacilli
 The route of transmission of TB
 Whether the materials handled and the manipulations
required for each procedure are likely to generate infectious
 The number of manoeuvres in each technique that may
generate aerosols
 The workload of the laboratory and of individual staff
 The location of the laboratory
 The epidemiology of the disease and the patient population
 The level of experience and competence of lab staff
 The health of lab staff (especially HIV-positive staff)
What are the steps in conducting a risk
• Identify potential hazards.
• Decide who might be harmed and how.
• Evaluate the risks and decide on precautions:
− Determine the suitability of the physical space
− Evaluate the staff’s proficiency in following safe
− Evaluate the integrity of safety equipment
• Record your findings and implement any necessary
• Review your assessment and update it when
• A risk-assessment tool is available at
Relative risks from exposure to infectious
Higher Doctors and nursing staff in TB ward

Healthcare workers assisting

with specimen collection

Lower Laboratory technicians processing

specimens for smear microscopy
risk or
the Xpert MTB/RIF assay
Risk precaution level: Low risk

Risk level of TB Laboratory Assessment of risk

laboratory activities

Low risk Preparing Procedures have a

specimens for low risk of
smear microscopy generating
or Xpert MTB/RIF infectious aerosols
testing from specimens;
the concentration
of infectious
particles is low
Risk precaution level: Moderate risk
Risk level of Laboratory Assessment of
TB laboratory activities risk

Moderate risk Processing and Procedures have a

concentrating moderate risk of
specimens for Xpert generating
MTB/RIF testing or infectious aerosols;
inoculation onto the concentration
primary culture of infectious
media; splitting particles is low to
specimens; direct moderate
DST (for example, LPA
on processed
Risk precaution level: High risk

Risk level of TB Laboratory Assessment of

laboratory activities risk

High risk Culture Procedures have a

(TB-containment manipulation for high risk of
laboratory) identification; DST or generating infectious
LPA on cultured aerosols; the
isolates concentration of
infectious particles is
Safety practices: Adequate ventilation

• Adequate ventilation for TB laboratories is

typically described as directional airflow with
6–12 air exchanges per hour (ACH)

• Directional airflow refers to air moving from

clean areas across areas where aerosols may
be generated (dirty areas) and then to the
Module 3: IPC and safety practice
By the end of this Module, the participants will be able to:
• Describe the elements of TB IPC Plan
• Describe TB IPC Procedures and practices in facilities
• Describe the various interventions aimed at promoting IPC
• Describe how IPC will be monitored
• Safety practices in the TB microscopy laboratory and the
Xpert MTB/RIF laboratory
• Safe disposal of infectious waste
Elements of a TB IC plan—
national or facility
• Responsible authority
• List highest risk settings and how defined
• Recommended set of IC measures
• Policies
• Human resource development
• Advocacy, communication, social
• Monitoring and evaluation indicators
• Budget
Safety practices: Airflow
• Use of bench spaces: The bench used to process
specimens for direct sputum-smear microscopy or
the Xpert MTB/RIF assay should be separate from
areas where specimens are received and from
areas where paperwork is completed and
telephones are used.
• Ventilation: When appropriate microbiological
techniques are used, direct smear testing and
direct processing of specimens for the Xpert
MTB/RIF assay may both be carried out on an open
bench in an adequately ventilated area.
AII Precautions for Inpatient Settings
Administrative Environmental Respiratory
Controls Controls Protection
Lab-specific risk Handle specimens Lab specific based
assessment and IC suspected to contain on risk assessment
plan M. tuberculosis and
At least N95. Use if
Biosafety level (BSL) aerosol-producing
procedures in class I
2 for non-aerosol- procedures
or II biological safety
producing performed outside
cabinet (BSC).
procedures BSC
Annual HCW M.
tuberculosis testing
in med. and high-
risk settings
Monitor infection control Practices

• What gets measured gets done.

• Examples
Measure laboratory turn-around time
for sputum specimens.
Have a staff member observe specific IC
practices daily for one week.
Keep track of number of health workers
in the facility who develop TB during 6
month period
• A disinfectant is a chemical or mixture of
chemicals used to kill microorganisms.
• Disinfectants are usually applied to
surfaces or inanimate objects.
• Disinfectants may be used before
autoclaving for pre-decontamination
NOTE: Because of the specific cell-wall structure of TB
bacilli, they are resistant to most standard disinfectants
– that is, quaternary ammonium compounds are
• Select disinfectants that are effective against mycobacteria
based on the material to be disinfected
 PHENOL 2-5% in deionized water is highly irritating, and caution must be used in
preparation. It is preferable to use phenolic derivatives:
• Decontaminate equipment, surfaces and items or liquids before disposal (wear
• Prepare the solution daily and leave in contact with the surface for at least 15
minutes to ensure decontamination.
 CHLORINE (sodium hypochlorite, or bleach with 0.72% active chlorine) is an irritant,
and is corrosive to metals and plastics:
• It is a general purpose disinfectant; also can be used to soak contaminated items
• Allow at least 15 minutes to ensure decontamination
• Prepare daily and store in a well-ventilated area (toxic gas). Do not autoclave.
 ALCOHOL 70% leaves no residue but is volatile and flammable (keep far from open
• Use as a disinfectant on skin (follow by washing with soap) and work surfaces
(including metals).
 PERACETIC ACID leaves no residue, but is stable for only 48 hours after preparation:
• Rapid action against all microorganisms.
Spill kit
• All laboratories handling samples for TB diagnostic testing
should have a spill kit containing:
- Instructions (SOPs) for cleaning up spills
- A large biohazard bag (autoclavable)
- Suitable tuberculocidal disinfectant, such as hypochlorite
(freshly prepared) or phenol-derivatives, stored in
opaque bottles
- Laboratory gowns (disposable) and goggles
- Box of gloves (different sizes)
- Respirators (N95 or FFP2)
- Paper towels, cotton wool or absorbent cloths
- Soap and chloramine tablets
- Dustpan
- Sharps container
- “DO NOT ENTER” sign.
• Check the contents of the spill kit regularly and replace
items after use or when they have expired.
Spill clean-up procedures
Spill outside the BSC (major event) (1 of 2)
– Immediately vacate and secure the laboratory, and
inform the laboratory manager/supervisor.
– Leave the laboratory’s ventilation or exhaust systems
on, including in the BSC.
– Do not re-enter the laboratory for at least 1 hour (post
DO NOT ENTER signs).
– Before re-entering the laboratory, put on clean gloves,
a clean laboratory coat and a respirator.
– Cover the spill (or spills) with cloths or absorbent
paper, and soak the paper with a suitable disinfectant;
apply the disinfectant concentrically, from the outer
margin towards the centre of the spill.
– Allow sufficient time for the disinfectant to act (at least
30-60 minutes) before disposing of any material.
Spill clean-up procedures
• Spill within the BSC (1 of 2)
 Cover the spill area with cloths or absorbent
paper, and apply a suitable disinfectant
concentrically – that is, from the outer margin
towards the centre of the spill:
o Any equipment or material that has been splashed must be cleaned (including
the interior surfaces and walls of the BSC, or safety buckets)
o Do not use bleach to disinfect metal parts (it is corrosive).
 Allow sufficient time for the disinfectant to act
(30-60 minutes) before disposing of any material.
Waste disposal
• At the end of each day, seal All used materials should
contaminated material (such be considered to be
as used sputum containers,
transfer pipettes and used
cartridges) in a biohazard bag,
and autoclave or incinerate or
bury it as soon as possible
 Warning: incinerating plastics
can release toxins that are
harmful to breathe
• Decontaminate transfer
pipettes using an appropriate
disinfectant prior to disposal.
PPE: Gloves
• Gloves are required for processing
specimens for TB diagnosis.
• Use disposable powder-free gloves,
is recommended for Xpert Mtb rif
• Wearing gloves may give technicians
a false sense of safety:
 Regular and thorough handwashing
remains essential
• To avoid contamination remove
gloves before using computer
terminals or telephones
• DO NOT reuse gloves
• DO NOT wear gloves outside the
PPE: Laboratory coats
Laboratory coats are essential:
 Leave coats at the worksite
– do not take coats home
 Fasten the laboratory coat
when worn
 Use appropriate size and
 DO NOT wear outside of the
 Launder at least weekly, and
after any overt contamination
(do not take the coat home);
disinfect before laundering.
PPE: Respirators
• N95 and FFP2 respirators effectively filter out >94-
95% of particles ≥0.3-0.4 µm in diameter.
• Respirators must be fitted to the face! (Use the
Respirators protect the
wearer from inhaling
droplet nuclei
(they protect against

• Surgical masks do not protect the wearer against

inhaling infectious aerosols.
Surgical masks prevent
spreading from the
wearer (they protect
others from exhalation)
Module 4: Available TB laboratory
By the end of the course the participant will be able to:
 Describe the biological characteristics of MTB
• Have knowledge on the current laboratory diagnostic
• Demonstrate knowledge and use of each diagnostic
• Understand how to interpret TB laboratory tests
– Smear
– Xpert MTB/RIF
– Culture
– Drug susceptibility test
• Understand Xpert MTB/RIF algorithm
• Understand SOPs for Xpert MTB/RIF testing
TB diagnosis, treatment monitoring and
Diagnosis Surveillance
• Smear Microscopy –ZN/FM  Molecular tests e.g
• GeneXpert LPA,Xpert MTB/RIF
 Chest X-ray (for smear negative TB) - TB Culture
- Drug Susceptibility Test

Treatment monitoring
• Smear Microscopy
• TB Culture
• Supportive PMDT investigation
 LFT’s
 UEC’s
Trends on new tests and has WHO policies
have reduced TAT since 2007
Turnaroun Sensitivity
Year Technology
d time gain

Ziehl-Neelsen <1 day, though

Before 2007 microscopy; often batched Baseline
solid culture 30-60 days

+10% compared
Liquid culture/DST; with Löwenstein-
2007 15-30 days Jensen
rapid speciation
solid culture
Smear Microscopy
• Microscopy is recommended for ALL levels of laboratories
(that is, peripheral and higher levels)

• Microscopy is required to monitor responses to anti-TB


• Microscopy has limited sensitivity, which is further

reduced in HIV-co infected individuals

• WHO recommends that in all settings LED fluorescence

microscopy should be phased in to replace conventional
bright-field microscopy and Ziehl-Neelsen staining
AFB Microscopy-ZN/FM stain
• Mycobacteria are
called Acid-Fast Bacilli
(AFB) due to their
appearance after
• Organisms appear
red on a blue
Why take a skin smear for leprosy
• To confirm a diagnosis of skin smear-positive
multibacillary leprosy in a presumptive

• To help diagnose multibacillary relapse in a

patient who has previously been treated

• To help with the classification of new patients

Molecular Diagnostic Test
Molecular Diagnostic Tests

Molecular XpertMTB/RIF
diagnostic tests • Automated machine that uses a
• Gene expert – polymerase chain reaction (PCR)
detects R to break apart and identify strips
resistance of DNA
• Line Probe Assay • Tests for the presence of
– Genotype Mycobacteria Tb. genes as well
MTBDR assay as the genes associated with
(hain lifescince)- Rifampicin (RIF) resistance
detects both R
and H resistance • Can be used on raw
(unprocessed) sputum
• Results available in 2 hours
Indications for GeneXpert in Kenya
• Low risk for DR TB
All presumptive TB cases who are not in the high risk group including:
• People Living with HIV with TB symptoms
• Children <15 years with TB symptoms
• All presumptive TB cases with a negative smear microscopy result

• High risk for DR TB

• Previously treated TB patients: treatment failures, relapses, treatment after loss
to follow up
• Drug Resistant TB patient contacts
• TB patients with a positive smear result at month 2 or month 5 of TB treatment
• Patient who develops TB symptoms while on IPT or has had previous IPT
• Healthcare Workers with TB symptoms
• Prisoners with TB symptoms
• Refugees with TB symptoms

• GeneXpert test is the preferred first test for TB diagnosis and identification of
rifampicin resistance in all presumptive TB cases*
• Patients diagnosed using geneXpert should be followed up using smear microscopy
• In situations where geneXpert is not available, smear microscopy may be used for
initial TB diagnosis and concurrently, a sample specimen sent for geneXpert test.
Limitations of Gene Xpert
– Currently test sensitivity for
Rifampicin only
– Not validated for processing specimen
other than sputum
– Not used for DRTB follow-up
– Expensive
– Short expiry of cartilages (usually one
year shelf-life)
– Requires electricity
Xpert Results Interpretation
1. T =MTB detected, Rifampicin resistance not
2. RR =MTB detected, Rifampicin resistance detected;
3. N = MTB not detected;
4. TI = MTB detected, Rifampicin resistance
5. I = Invalid/error
6. No result

Inconclusive results
repeat GeneXpert
Managing Discordant results
1. Smear-Neg microscopy vs. MTB detected by Xpert
– Will be common
– RIF Resistance detected –
 collect sample for culture & DST ,
 Start treatment with cat iv
– RIF resistance not detected –
 collect sample for culture & DST for the surveillance group
 Start treatment with cat 1
 RIF resistance indeterminate- repeat GeneXpert but
emphasize on (quality sample ) proper sample collection
2. Smear-pos microscopy vs. MTB not detected by Xpert
– Will be rare
– Lab error
– Repeat both sputum microscopy and Gene Xpert
– Consider Non Tuberculous Mycobacteria
Managing Discordant results cont..
3. RIF-resistance detected by Xpert vs. not detected by
culture/DST (Discordant Xpert & Culture & DST results)
– Repeat Gene Xpert
– continue MDR TB regimen
– Clinical team discussion (County and
– Inform PMDT coordinator and NTRL/Kisian
lab person for sequencing

 NB: Culture/DST should not be used to confirm / reject GeneXpert results

 NB. Gene Xpert is still the preferred 1st line test for diagnosis of TB in HIV+
patients where available
 In case sputum microscopy was done prior to or in addition to genexpert,
discordant results should be interpreted as above
Module 5: Quality assurance/
quality control
• At the end of this module, participants will
be able to:
– Define Quality assurance and control
– Establish the key indicators to monitor in
– Demonstrate understanding on the role of QA
in results acceptability & reproducibility
– Document the necessary measures to develop
proper QA systems
– Role of EQA in QA/QC
Quality Assurance/Control
• Quality assurance (QA) is a system designed
to continuously improve the reliability and
efficiency of laboratory services.
• This system includes, quality control,
external quality assessment, quality
• Quality control (QC), a systematic internal
monitoring of working practices, technical
procedures, equipment and materials,
including quality of stains.
Key Components of Quality
Assurance Program

Environment Personnel Equipment Supplies Specimens Internal External

Accurate and
- Safe and - Trained - Maintained - Uninterrupted - Good quality quality Quality
functional and and serviced supplies Labelled with monitoring Assessment
- Temperature competent - Appropriate unique ID - Test (EQA)
- Turnaround
control staff transport and - Completed working - Testing site‘s
- Test user is storage request form properly work checked
Results review
documented conditions by another
- Current site
SOPs readily

Accurate, reliable and timely results

EQA and Proficiency testing (PT)
• External quality assurance (EQA)
– A process that allows participant laboratories to assess
their capabilities by comparing their results with those
of other laboratories in the network through panel
testing and blinded rechecking.
• EQA also includes on-site evaluation of the laboratory to review
quality of performance and should include on-site re-reading of
• EQA is an expansion of the proficiency testing as described by
• Proficiency testing performance (PT)
– AFB smear microscopy
– Culture
– Drug susceptibility testing
QA/QC monitored indicators
• Recovery rate of MTB
– Percentage of MTB / total number of specimens
• Contamination rate (specimen, solid, liquid)
• Percentage of specimens reported as smear positive
– distribution of smear grades (actual/scanty, 1+, 2+,
• Correlation between positive smears and positive
• Percentage of negative smears resulting in positive
• Turn-around time of AFB smear, culture and DST results
• Proficiency testing performance (AFB microscopy,
culture, drug susceptibility testing)
• Percentage of Mtb positive with/out Rif, error rates,
Tuberculosis Culture and DST
Mycobacterium tuberculosis complex -

• Mycobacterium tuberculosis Complex (typical)

consists of; M tuberculosis, M. bovis, M.
africanum , M. Microtti and M. Canetti, M.
pinnipedii, M. caprae
– Acid-alcohol resistant bacilli
– Resistant to cold, freezing and desiccation
– Very sensitive to heat, sunlight, and UV radiation
– Strictly aerobic (depends on Oxygen and pH of 7.4).
– Polyvalent behaviour, depending on medium
– Very slow division capacity
M tuberculosis Complex progression

• M. tuberculosis complex takes 16-24 hrs.

to divide (60 times slower than S. aureus)
• Slow and insidious Clinical Presentation

• Excessive delay to consult the health care

• Very late diagnosis

• Long period of contagiousness prior to

Rapid Tests for DR-TB
• Conventional drug susceptibility takes 4-8
weeks for results, however
– Xpert Mtb rif PCR takes 2hrs – Mtb rif
resistance (presumptive cases )
– Line Probe assay takes 48hrs, both INH and
rif resistant
– Liquid culture (MGIT) takes 42 days
Culture for detection and
identification of TB
Culture more sensitive than microscopy
– Can detect as few as 10 – 100 viable bacteria / ml
– Important for HIV+ individuals who often have low bacillary loads
in sputum specimens
Processing of sputum prior to culture
– Digestion of mucus
– Decontamination of normal flora
– Concentration by centrifugation
Inoculation of liquid and solid media
– Detection of growth
– Characteristic cording following growth in liquid medium
– Confirm ID of AFB as M. tuberculosis – conventional and newer
– For sensitivity testing
• Solid 14 days
• Liquid 7 days
Growth detection on LJs
• Supports growth of most
– Growth can be quantified,
– Colony morphology and
pigmentation can be seen

• It is less likely to become

during preparation and inoculation

• Contamination usually involves the

surface of the medium so it is easily
Growth detection in liquid
• This is an automated
growth detection
• Benefits:
– Shorter turnaround
– Greater sensitivity
– Fully automated

• Challenges:
– Higher isolation rate of
– Higher contamination
Antigen detection assays for ID
• MTBC secrete soluble protein MPB64 into media when
– MPT64 and MPB64 differ by a one amino acid change resulting in
a silent mutation
– Protein is specific to the MTBC
• 3 assays
– Capilia
• Detects MTBC specific protein MPB64
– SD Bioline
• Detects MTBC specific protein MPT64
– Becton Dickinson TBc ID
• Detects MTBC specific MPT64
Molecular testing (MTBC Kit)
• 1st line
• SIRE- Takes 5-15 day
• Pyrazinamide 5-21 Days

• 2nd line
• Moxifloxacin,Ofloxacin,Amikacin,Kanamycin,
Capreomycin,Cyclocyrine,Ethionamide and PAS

Module 1 - Tuberculosis
Advantages of culture
Detects small numbers of organisms
(as few as 10 bacilli)
Confirms diagnosis of TB in HIV+
Allows species identification
Allows drug susceptibility testing and
DR surveillance
Allows epidemiological studies
Limitations of TB culture
Slow growth of MTB: long turn-around-
Expensive, limited number of labs
Essential Needs
– Adherence to strict biosafety procedures
– Adequate infrastructure: facility, electricity, water
– Training of qualified staff
– Equipment: proper use and maintenance
– Continuous supply of media and reagents
– Specimen transport system
– Quality management (appropriate organisms, organized
Disadvantages of conventional DST

• Conventional drug susceptibility testing is

slow, generally takes 4-6 weeks for results
• Delay in diagnosis of MDR-TB:
Increased mortality
Patients improperly treated until results are
Further resistance can occur
Patients continue to spread resistant strain

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